"Incident Report Form - Birkdate Baptist Church, Cannon Hill Baptist Church"

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INCIDENT REPORT
FORM 8
Program details
Name of ministry group
Ministry leader’s name
Phone
Location of Program
Church property
Camp Site
Private Property
Other
If other please advise:
Address
Suburb
State
Country
Incident details
Location where incident occurred (if different to above)
Address
Suburb
State
Country
Date
Time
AM / PM
Details of Child/Children involved
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
If additional Children involved then please attach details to report.
Description of Incident
Did the incident occur during an authorised activity/normal programme hours?
Yes / No
If yes, was the activity supervised?
Yes / No
Supervisor’s name
what
If yes,
activity was in progress at the time of the incident?
Please write a description of the incident (to the best of your knowledge) including relevant information
such as warnings given and what response was taken.
K:\BBC Documents\Policies, Procedures & Procedures, Codes of Conduct\Policies, Codes of Conduct\Child Protection\Forms\Form 8 Incident
Report.doc
INCIDENT REPORT
FORM 8
Program details
Name of ministry group
Ministry leader’s name
Phone
Location of Program
Church property
Camp Site
Private Property
Other
If other please advise:
Address
Suburb
State
Country
Incident details
Location where incident occurred (if different to above)
Address
Suburb
State
Country
Date
Time
AM / PM
Details of Child/Children involved
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
Full Name
Male / Female
Date of Birth
Address
Suburb
Post Code
Phone
If additional Children involved then please attach details to report.
Description of Incident
Did the incident occur during an authorised activity/normal programme hours?
Yes / No
If yes, was the activity supervised?
Yes / No
Supervisor’s name
what
If yes,
activity was in progress at the time of the incident?
Please write a description of the incident (to the best of your knowledge) including relevant information
such as warnings given and what response was taken.
K:\BBC Documents\Policies, Procedures & Procedures, Codes of Conduct\Policies, Codes of Conduct\Child Protection\Forms\Form 8 Incident
Report.doc
If yes then please obtain the following
Were there witnesses to the incident?
Yes / No
Witness’ details
Name
Address
Suburb
Postcode
Phone
BH
AH
Mobile
Email
Please ask the witnesses to write down what they saw and attach it to this report.
Contacted
Parents / Guardian
By
When
Police / Emergency services
By
When
Church leadership
By
When
Follow up action taken
By
When
Name of person completing this form:
Date
Phone
BH
AH
Mobile
Email
Address
Parent/Guardian’s acknowledgement.
I acknowledge that I have received a copy of the completed Incident Form
Name
Signature
Date
K:\BBC Documents\Policies, Procedures & Procedures, Codes of Conduct\Policies, Codes of Conduct\Child Protection\Forms\Form 8 Incident
Report.doc
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